Histochemical and cytochemical methods for detecting ntrk fusion proteins

ABSTRACT

Materials and methods for detecting NTRK rearrangements via affinity staining. Samples are stained with a biomarker-specific reagent (such as an antibody) that binds to a retained portion of TrkA, TrkB, and/or TrkC. The staining pattern is evaluated, and the presence of a Trk fusion is determined by detecting whether or not the sample has at least a threshold number of cells having a threshold staining intensity. In some cases, the same scoring methodology is applied regardless of the staining localization pattern. In other cases, a cytoplasmic and/or membranous localization is scored by a first methodology, whereas a nuclear localization is scored by a second methodology. The methods disclosed herein may be applied across non-endocrine solid tumor types.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of PCT/EP2019/074463, filed Sep. 13, 2019, which claims the benefit of U.S. Provisional Patent Application No. 62/731,032, entitled HISTOCHEMICAL AND CYTOCHEMICAL METHODS FOR DETECTING NTRK FUSION PROTEINS, filed on Sep. 13, 2018, the content of each which is incorporated herein by reference in its entirety.

SEQUENCE LISTING INCORPORATION BY REFERENCE

This application hereby incorporates-by-reference a sequence listing submitted herewith in a computer-readable format, having a file name of “P35023US 1_SeqList_ST25” created on Feb. 1, 2021, which is 21,275 bytes in size.

TECHNICAL FIELD

The present disclosure relates, among other things, to methods for the histochemical and cytochemical detection of fusion proteins involving NTRK gene products; materials, kits, and systems useful in such methods; and products resulting from performance of such methods.

BACKGROUND

Neurotrophic tyrosine receptor kinases (NTRK1, NTRK2, and NTRK3) are a gene family encoding receptor tyrosine kinase proteins (TRKA, TRKB and TRKC) which play a role in the development and maturation of the central and peripheral nervous systems (Barbacid I, Barbacid II, Lemmon & Schlessinger, and Klein). In cancer, the intact kinase domain of one of the three NTRK genes can fuse to a variety of upstream partners (e.g. ETV6, LMNA, TPM3) replacing the TRK protein's ligand binding domain with structural motifs promoting dimerization (Eide, Luberg, & Vaishnavi). This results in constitutive activation of TRK signaling and unchecked proliferation, resulting from expression of the fusion protein.

NTRK gene fusions are pathognomonic in certain rare tumors such as infantile fibrosarcoma, congenital mesoblastic nephroma, secretory breast cancer and secretory carcinoma (MASC) of the salivary gland (Argani, Bishop, Bourgeois, Rubin, & Tognon). Conversely, NTRK gene fusions occur rarely in a variety of adult and pediatric solid tumors, including but not limited to: appendiceal cancer, breast cancer, cholangiocarcinoma, colorectal cancer (CRC), GIST, lung cancer, melanoma, pancreatic cancer, thyroid cancer, and diverse sarcomas (DeBraud, Brzezianska, Fernandez-Cuesta, Leeman-Neill, & Ross). Identifying NTRK gene fusions is clinically important because of the availability of small molecule inhibitors currently in development for the treatment of solid tumors with NTRK gene fusions (Vaishnavi & De Braud).

To date, there is no gold standard for detection of NTRK fusions in tumors due to inconsistent specificity and sensitivity across different methodologies. Current methods of detection include fluorescence in situ hybridization (FISH), in situ hybridization (ISH), Next Generation Sequencing (NGS), and immunohistochemistry (IHC). Optimization and enumeration/interpretation of FISH and ISH assays can be difficult. NGS is highly specific, but lacks sensitivity. In contrast, IHC can be highly sensitive, but detects protein expression rather than the presence of actual fusion. Additionally, due to endogenous presence of wild-type TRK protein in some tumors (namely neuroendocrine tumors and GISTs), optimization of an IHC assay to the fusion product, and in turn, development of a specific scoring algorithm to select for this fusion product, can be challenging.

SUMMARY

The present disclosure relates to methods for identifying non-neuroendocrine tumors that are driven by TRK fusion proteins.

In an embodiment, a method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample is provided, the method comprising: affinity histochemically staining the sample with a biomarker-specific reagent that specifically binds to one or more of: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3; detecting staining pattern in the sample; and scoring the sample as positive for a fusion protein involving TrkA, TrkB, or TrkC if: the sample has a cytoplasmic and/or membranous staining pattern and has a greater than or equal to a first threshold percentage of tumor cells staining above a pre-determined specific staining intensity; or the sample has a nuclear staining pattern and greater than or equal to a second threshold percentage of cells within a threshold tumor cell area that are specifically stained at any intensity.

In an embodiment, a method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample is provided, the method comprising: affinity histochemically staining the sample with a biomarker-specific reagent that specifically binds to: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; and an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3; detecting staining pattern in the sample; and scoring the sample as positive for a fusion protein involving TrkA, TrkB, or TrkC if: the sample has a cytoplasmic and/or membranous staining pattern and has a greater than or equal to a first threshold percentage of tumor cells staining above a pre-determined specific staining intensity; or the sample has a nuclear staining pattern and greater than or equal to a second threshold percentage of cells within a threshold tumor cell area that are specifically stained at any intensity.

In an embodiment, a method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample is provided, the method comprising: affinity histochemically staining the sample with a biomarker-specific reagent that specifically binds to an amino acid sequence consisting of amino acids 816-838 of SEQ ID NO: 2; detecting staining pattern in the sample; and scoring the sample as positive for a fusion protein involving TrkA, TrkB, or TrkC if: the sample has a cytoplasmic and/or membranous staining pattern and has a greater than or equal to a first threshold percentage of tumor cells staining above a pre-determined specific staining intensity; or the sample has a nuclear staining pattern and greater than or equal to a second threshold percentage of cells within a threshold tumor cell area that are specifically stained at any intensity.

In an embodiment, a method of detecting an NTRK rearrangement in a non-neuroendocrine tumor sample is provided, the method comprising detecting the presence of a Trk fusion protein in the sample according to a method described herein, and confirming the presence of an NTRK rearrangement by screening the sample by sequencing, reverse transcriptase polymerase chain reaction, or in situ hybridization if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC.

In an embodiment, a method of selecting a patient to receive a Trk-directed therapy is provided, the method comprising detecting the presence of a Trk fusion protein or an NTRK rearrangement in a non-neuroendocrine tumor sample according to a method described herein, and selecting the patient to receive the therapy if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC or the NTRK rearrangement is detected.

In an embodiment, methods of staining samples for the presence or absence of TrkA, TrkB, or TrkC, and fusion proteins involving the kinase domain thereof, are also provided, the methods comprising (a) subjecting the sample to a heat-induced epitope retrieval process; and (b) contacting the sample with the biomarker-specific reagent and a set of detection reagents to deposit a brightfield dye in proximity to any biomarker-specific reagent bound to the sample, wherein the biomarker-specific reagent specifically binds to one or more of: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3.

In an embodiment, methods of staining samples for the presence or absence of TrkA, TrkB, or TrkC, and fusion proteins involving the kinase domain thereof, are also provided, the methods comprising (a) subjecting the sample to a heat-induced epitope retrieval process; and (b) contacting the sample with the biomarker-specific reagent and a set of detection reagents to deposit a brightfield dye in proximity to any biomarker-specific reagent bound to the sample, wherein the biomarker-specific reagent is a primary antibody that specifically binds to one or more of: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3; and wherein the set of detection reagents comprises a secondary antibody immunoreactive with the primary antibody, a tertiary antibody immunoreactive with the secondary antibody conjugated to an enzyme, and a set of reagents reactive with the enzyme to effect deposition of a brightfield dye on the sample.

In an embodiment, methods of staining samples for the presence or absence of TrkA, TrkB, or TrkC, and fusion proteins involving the kinase domain thereof, are also provided, the methods comprising (a) subjecting the sample to a heat-induced epitope retrieval process; and (b) contacting the sample with the biomarker-specific reagent and a set of detection reagents to deposit a brightfield dye in proximity to any biomarker-specific reagent bound to the sample, wherein the biomarker-specific reagent is a primary antibody that specifically binds to each of: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3; and wherein the set of detection reagents comprises a secondary antibody immunoreactive with the primary antibody, a tertiary antibody immunoreactive with the secondary antibody conjugated to an enzyme, and a set of reagents reactive with the enzyme to effect deposition of a brightfield dye on the sample. Other embodiments will be apparent from the following disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee.

FIG. 1 Sequence alignment between exemplary retained portions of TrkA (amino acid residues 363-760 of SEQ ID NO: 1), TrkB (amino acid residues 646-838 of SEQ ID NO: 2) and TrkC (amino acid residues 718-839 of SEQ ID NO: 3). The sequence alignment was generated using the Kalign Multiple Sequence Alignment tool from EMBL-EBI (https://www.ebi.ac.uk/Tools/msa/kalign/). Default settings were used, which include a ClustalW output format, a Gap Open Penalty of 11, a Gap Extension Penalty of 0.85, Terminal Gap Penalties of 0.45, and Bonus Score of 0.

FIG. 2A IHC results for Trk-fusions in multiple tumor types. Orthogonal testing methods were used to assess for presence of Trk fusions.

FIG. 2B IHC results for Trk-fusions in multiple tumor types. Orthogonal testing methods were used to assess for absence of Trk fusions.

FIG. 3A The staining distribution of tumor types with ISH-confirmed fusion-positive cases in the dataset by percentage of tumor cells staining (0-100%) and by intensity of the staining (0-3+). Circles depict fusion-negative cases while triangles represent fusion-positive cases. Diamonds indicate cases in which fusions were detected by ISH, but fixation gradient was observed. Patterns represent various tumor histologies. FIG. 5a shows and FIG. 5b shows the staining distribution of neuroendocrine tumors where no fusion-positive cases were detected.

FIG. 3B The staining distribution of tumor types with ISH-confirmed fusion-negative cases in the dataset by percentage of tumor cells staining (0-100%) and by intensity of the staining (0-3+).

FIG. 4 Sub-categorization of solid tumors based on IHC and ISH testing.

FIG. 5 Examples of differences in staining pattern localizations obtained with the staining methods described herein. (A) Cytoplasmic/membranous staining pattern in a colorectal tumor determined to have a NTRK1 rearrangement by break-apart in situ hybridization assay, confirmed to be a NTRK1-TPM3 fusion by next-generation sequencing. (B) Cytoplasmic staining pattern in a colorectal tumor determined to have a NTRK1 rearrangement by break-apart in situ hybridization assay, confirmed to be a NTRK1-EML4 fusion by next-generation sequencing. (C) Nuclear/cytoplasmic staining pattern in a mammary analogue secretory carcinoma (MASC) determined to have a NTRK3 rearrangement by break-apart in situ hybridization assay, confirmed to be a NTRK3-ETV6 fusion by next-generation sequencing.

FIG. 6 Examples of fixation gradients in the tissues and demonstration that nuclear localizations appear to be more affected by the gradients than the cytoplasmic/membrane localizations. Bottom row shows low magnification and top row shows high magnification of a subsection of the image immediately below.

DETAILED DESCRIPTION I. Definitions

Unless defined otherwise, technical and scientific terms used herein have the same meaning as commonly understood by a person of ordinary skill in the art. See, e.g., Lackie, DICTIONARY OF CELL AND MOLECULAR BIOLOGY, Elsevier (4th ed. 2007); Sambrook et al., MOLECULAR CLONING, A LABORATORY MANUAL, Cold Springs Harbor Press (Cold Springs Harbor, N.Y. 1989). The term “a” or “an” is intended to mean “one or more.” The terms “comprise,” “comprises,” and “comprising,” when preceding the recitation of a step or an element, are intended to mean that the addition of further steps or elements is optional and not excluded.

Antibody: The term “antibody” herein is used in the broadest sense and encompasses various antibody structures, including but not limited to monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), and antibody fragments so long as they exhibit the desired antigen-binding activity.

Antibody fragment: An “antibody fragment” refers to a molecule other than an intact antibody that comprises a portion of an intact antibody that binds the antigen to which the intact antibody binds. Examples of antibody fragments include but are not limited to Fv, Fab, Fab′, Fab′-SH, F(ab′)2; diabodies; linear antibodies; single-chain antibody molecules (e.g. scFv); and multispecific antibodies formed from antibody fragments.

Biomarker: As used herein, the term “biomarker” shall refer to any molecule or group of molecules found in a biological sample that can be used to characterize the biological sample or a subject from which the biological sample is obtained. For example, a biomarker may be a molecule or group of molecules whose presence, absence, or relative abundance is:

-   -   characteristic of a particular cell or tissue type or state;     -   characteristic of a particular pathological condition or state;         or     -   indicative of the severity of a pathological condition, the         likelihood of progression or regression of the pathological         condition, and/or the likelihood that the pathological condition         will respond to a particular treatment.

As another example, the biomarker may be a cell type or a microorganism (such as a bacteria, mycobacteria, fungi, viruses, and the like), or a substituent molecule or group of molecules thereof.

Biomarker-specific reagent: A specific detection reagent that is capable of specifically binding directly to one or more biomarkers in the cellular sample, such as a primary antibody.

Cellular sample: As used herein, the term “cellular sample” refers to any sample containing intact cells, such as cell cultures, bodily fluid samples or surgical specimens taken for pathological, histological, or cytological interpretation.

Cytochemical detection: A process involving labelling biomarkers or other structures in a cytological sample with biomarker-specific reagents and detection reagents in a manner that permits microscopic detection of the biomarker or other structures in the context of intact cells.

Cytological sample: As used herein, the term “cytological sample” shall refer to a cellular sample that either have no cross-sectional spatial relationship in vivo (such as cellular samples derived from blood samples, urine samples, sputum, etc.) or in which the cross-sectional spatial relationship has been at least partially disrupted (such as tissue smears, liquid-based cytology samples, fine needle aspirates, etc.).

Detection reagent: A “detection reagent” is any reagent that is used to deposit a stain in proximity to a biomarker-specific reagent in a cellular sample. Non-limiting examples include biomarker-specific reagents (such as primary antibodies), secondary detection reagents (such as secondary antibodies capable of binding to a primary antibody), tertiary detection reagents (such as tertiary antibodies capable of binding to secondary antibodies), enzymes directly or indirectly associated with the biomarker specific reagent, chemicals reactive with such enzymes to effect deposition of a fluorescent or chromogenic stain, wash reagents used between staining steps, and the like.

Detectable moiety: A molecule or material that can produce a detectable signal (such as visually, electronically or otherwise) that indicates the presence (i.e. qualitative analysis) and/or concentration (i.e. quantitative analysis) of the detectable moiety deposited on a sample. A detectable signal can be generated by any known or yet to be discovered mechanism including absorption, emission and/or scattering of a photon (including radio frequency, microwave frequency, infrared frequency, visible frequency and ultra-violet frequency photons). The term “detectable moiety” includes chromogenic, fluorescent, phosphorescent, and luminescent molecules and materials, catalysts (such as enzymes) that convert one substance into another substance to provide a detectable difference (such as by converting a colorless substance into a colored substance or vice versa, or by producing a precipitate or increasing sample turbidity). In some examples, the detectable moiety is a fluorophore, which belongs to several common chemical classes including coumarins, fluoresceins (or fluorescein derivatives and analogs), rhodamines, resorufins, luminophores and cyanines. Additional examples of fluorescent molecules can be found in Molecular Probes Handbook—A Guide to Fluorescent Probes and Labeling Technologies, Molecular Probes, Eugene, Oreg., ThermoFisher Scientific, 11^(th) Edition. In other embodiments, the detectable moiety is a molecule detectable via brightfield microscopy, such as dyes including diaminobenzidine (DAB), 4-(dimethylamino) azobenzene-4′-sulfonamide (DABSYL), tetramethylrhodamine (DISCOVERY Purple), N,N′-biscarboxypentyl-5,5′-disulfonato-indo-dicarbocyanine (Cy5), and Rhodamine 110 (Rhodamine).

Histochemical detection: A process involving labelling biomarkers or other structures in a tissue sample with biomarker-specific reagents and detection reagents in a manner that permits microscopic detection of the biomarker or other structures in the context of the cross-sectional relationship between the structures of the tissue sample.

Monoclonal antibody: An antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical and/or bind the same epitope, except for possible variant antibodies, e.g., containing naturally occurring mutations or arising during production of a monoclonal antibody preparation, such variants generally being present in minor amounts. In contrast to polyclonal antibody preparations, which typically include different antibodies directed against different determinants (epitopes), each monoclonal antibody of a monoclonal antibody preparation is directed against a single determinant on an antigen. Thus, the modifier “monoclonal” indicates the character of the antibody as being obtained from a substantially homogeneous population of antibodies, and is not to be construed as requiring production of the antibody by any particular method. For example, the monoclonal antibodies to be used in accordance with the present invention may be made by a variety of techniques, including but not limited to the hybridoma method, recombinant DNA methods, phage-display methods, and methods utilizing transgenic animals containing all or part of the human immunoglobulin loci, or a combination thereof.

“Retained portion” shall mean any portion of a wild-type counterpart of an oncogenic fusion protein that is preserved in the oncogenic fusion protein.

Specific binding: As used herein, the phrase “specific binding,” “specifically binds to,” or “specific for” or other similar iterations refers to measurable and reproducible interactions between a target and a specific detection reagent, which is determinative of the presence of the target in the presence of a heterogeneous population of molecules including biological molecules. For example, an antibody that specifically binds to a target is an antibody that binds this target with greater affinity, avidity, more readily, and/or with greater duration than it binds to other targets. In one embodiment, the extent of binding of a specific detection reagent to an unrelated target is less than about 10% of the binding of the antibody to the target as measured, e.g., by a radioimmunoassay (RIA). In certain embodiments, a biomarker-specific reagent that specifically binds to a target has a dissociation constant (Kd) of ≤1 μM, ≤100 nM, ≤10 nM, ≤1 nM, or ≤0.1 nM. In another embodiment, specific binding can include, but does not require exclusive binding.

Specific detection reagent: Any composition of matter that is capable of specifically binding to a target chemical structure in the context of a cellular sample.

Stain: When used as a noun, the term “stain” shall refer to any substance that can be used to visualize specific molecules or structures in a cellular sample for microscopic analysis, including brightfield microscopy, fluorescent microscopy, electron microscopy, and the like. When used as a verb, the term “stain” shall refer to any process that results in deposition of a stain on a cellular sample.

Subject: As used herein, the term “subject” or “individual” is a mammal. Mammals include, but are not limited to, domesticated animals (e.g., cows, sheep, cats, dogs, and horses), primates (e.g., humans and non-human primates such as monkeys), rabbits, and rodents (e.g., mice and rats). In certain embodiments, the individual or subject is a human.

Test sample: A tumor sample obtained from a subject having an unknown outcome at the time the sample is obtained.

Tissue sample: As used herein, the term “tissue sample” shall refer to a cellular sample that preserves the cross-sectional spatial relationship between the cells as they existed within the subject from which the sample was obtained.

Tumor sample: A tissue sample obtained from a tumor.

II. Staining Methods

The disclosure is based on affinity histochemically or cytochemically-stained samples of non-neuroendocrine NTRK fusion proteins using a first biomarker specific reagent that targets a retained portion of one or more of TrkA, TrkB, and TrkC. The biomarker-specific reagent is selected by identifying the breakpoint of the wild-type protein that results in the fusion protein, and targeting a portion of the wild-type protein on the side of the breakpoint retained in the fusion protein. Many resources are available for identifying fusion protein breakpoints including, for example, the COSMIC database, which includes notations of breakpoints by genomic location and by the first exon expressed in the resulting fusion protein. Exemplary wild-type protein sequences are set forth in Table 1:

TABLE 1 Wild- type Exemplary amino protein acid sequence Background References TrkA Uniprot P04629-3 Amatu et al.; Stransky et al. (SEQ ID NO: 1) TrkB Uniprot Q16620-4 Amatu et al.; Stransky et al. (SEQ ID NO: 2) TrkC Uniprot Q16288-1 Amatu et al.; Stransky et al. (SEQ ID NO: 3) Exemplary breakpoints and consensus retained portions for fusion proteins retaining the C-terminus of TrkA, TrkB, or TrkC are illustrated in Table 2:

TABLE 2 Wild- First type Fusion Observed protein Partner Exon Consensus Retained Portion TrkA LMNA 10‡ Exon 10 through C-terminus TFG  6‡ (Residues 363-760 of SEQ ID NO: 1) TP53  9‡ TPM3 10‡ TrkB AFAP1 12* Exon 17 through C-terminus NACC2 13‡ (Residues 646-838 of SEQ ID NO: 2) QKI 16‡ PAN3 17* SQSTM 16  (terminates at exon 20)* TRIM24 15* TrkC ETV6 15‡ Exon 15 through C-terminus 14‡ (Residues 718-839 of SEQ ID NO: 3) TECR 10*

In an embodiment, the biomarker-specific reagent specifically binds to a retained portion of one or more of TrkA, TrkB, and TrkC. In an embodiment, the biomarker-specific reagent specifically binds to a retained portion of each of TrkA, TrkB, and TrkC. An alignment between exemplary retained portions of TrkA, TrkB, and TrkC is illustrated at FIG. 1. In another specific embodiment, the biomarker-specific reagent specifically binds to one or more of: (a) an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; (b) an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or (c) an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3. In another specific embodiment, the biomarker-specific reagent specifically binds to: (a) an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; (b) an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; and (c) an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3.

The biomarker-specific reagent may be any type of entity that is useful for in situ detection of proteins expressed by a cellular sample (such as by in histological or cytological staining methods). Exemplary biomarker-specific reagents include antibodies and antigen binding fragments thereof and engineered specific binding compositions, such as ADNECTINs (scaffold based on 10th FN3 fibronectin; Bristol-Myers-Squibb Co.), AFFIBODYs (scaffold based on Z domain of protein A from S. aureus; Affibody AB, Solna, Sweden), AVIMERs (scaffold based on domain A/LDL receptor; Amgen, Thousand Oaks, Calif.), dAbs (scaffold based on VH or VL antibody domain; GlaxoSmithKline PLC, Cambridge, UK), DARPins (scaffold based on Ankyrin repeat proteins; Molecular Partners AG, Zürich, CH), ANTICALINs (scaffold based on lipocalins; Pieris AG, Freising, DE), NANOBODYs (scaffold based on VHH (camelid Ig); Ablynx N/V, Ghent, BE), TRANS-BODYs (scaffold based on Transferrin; Pfizer Inc., New York, N.Y.), SMIPs (Emergent Biosolutions, Inc., Rockville, Md.), and TETRANECTINs (scaffold based on C-type lectin domain (CTLD), tetranectin; Borean Pharma A/S, Aarhus, DK). Descriptions of such engineered specific binding structures are reviewed by Wurch et al., Development of Novel Protein Scaffolds as Alternatives to Whole Antibodies for Imaging and Therapy: Status on Discovery Research and Clinical Validation, Current Pharmaceutical Biotechnology, Vol. 9, pp. 502-509 (2008), the content of which is incorporated by reference.

In a specific embodiment, the biomarker-specific reagent is an antibody. In another specific embodiment, the antibody is a monoclonal antibody (such as mouse monoclonal or rabbit monoclonal antibodies). In another specific embodiment, the antibody specifically binds to a retained portion of one or more of TrkA, TrkB, or TrkC. In another specific embodiment, the antibody specifically binds to an epitope contained in one or more of: (a) an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; (b) an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; or (c) an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3. In another specific embodiment, the antibody specifically binds to: (a) an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; (b) an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; and (c) an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3. In an embodiment, the antibody is a commercially available antibody according to Table 3:

TABLE 3 EPR17341 Abcam Rabbit monoclonal 816-838 of (ab181560) IgG SEQ ID NO: 2 B-3 Santa Cruz/ Mouse monoclonal 747-760 of Biotechnology Inc. IgG2a SEQ ID NO: 1 (sc-7268) In a specific embodiment, the antibody is EPR17341.

The biomarker-specific reagent is used to affinity histochemically or affinity cytochemically stain samples suspected of harboring a NTRK fusion protein. Affinity histochemical and cytochemical staining techniques typically involve contacting a sample deposited on a slide or other solid support with a biomarker-specific reagent under conditions sufficient to permit specific binding between the biomarker-specific reagent and the biomarker of interest. Binding of the biomarker-specific reagent to the biomarker facilitates deposition of a detectable moiety on the sample in proximity to locations containing the biomarker. The detectable moiety can be used to locate and/or quantify the biomarker to which the biomarker-specific reagent is directed. Thereby, the presence and/or relative amount of the target in a sample can be detected by detecting the signal produced by the detectable moiety.

The staining process may be manual, automated, or a combination of manual and automated steps. In an embodiment, the staining process may be carried out on an automated advanced staining platform. Automated advanced staining platforms typically include at least: reservoirs of the various reagents used in the staining protocols, a reagent dispense unit in fluid communication with the reservoirs for dispensing reagent to onto a slide, a waste removal system for removing used reagents and other waste from the slide, and a control system that coordinates the actions of the reagent dispense unit and waste removal system. In addition to performing staining steps, many automated slide stainers can also perform steps ancillary to staining (or are compatible with separate systems that perform such ancillary steps), including: slide baking (for adhering the sample to the slide), dewaxing (also referred to as deparaffinization), epitope retrieval, counterstaining, dehydration and clearing, and coverslipping. Prichard describes several specific examples of automated IHC/ISH slide stainers and their various features, including the intelliPATH (Biocare Medical), WAVE (Celerus Diagnostics), DAKO OMNIS and DAKO AUTOSTAINER LINK 48 (Agilent Technologies), BENCHMARK (Ventana Medical Systems, Inc.), Leica BOND, and Lab Vision Autostainer (Thermo Scientific) automated slide stainers. Additionally, Ventana Medical Systems, Inc. is the assignee of a number of United States patents disclosing systems and methods for performing automated analyses, including U.S. Pat. Nos. 5,650,327, 5,654,200, 6,296,809, 6,352,861, 6,827,901 and 6,943,029, and U.S. Published Patent Application Nos. 20030211630 and 20040052685, each of which is incorporated herein by reference in its entirety. Commercially-available staining units typically operate on one of the following principles: (1) open individual slide staining, in which slides are positioned horizontally and reagents are dispensed as a puddle on the surface of the slide containing a tissue sample (such as implemented on the DAKO AUTOSTAINER Link 48 (Agilent Technologies) and intelliPATH (Biocare Medical) stainers); (2) liquid overlay technology, in which reagents are either covered with or dispensed through an inert fluid layer deposited over the sample (such as implemented on VENTANA BenchMark and DISCOVERY stainers); (3) capillary gap staining, in which the slide surface is placed in proximity to another surface (which may be another slide or a coverplate) to create a narrow gap, through which capillary forces draw up and keep liquid reagents in contact with the samples (such as the staining principles used by DAKO TECHMATE, Leica BOND, and DAKO OMNIS stainers). Some iterations of capillary gap staining do not mix the fluids in the gap (such as on the DAKO TECHMATE and the Leica BOND). In variations of capillary gap staining termed dynamic gap staining, capillary forces are used to apply sample to the slide, and then the parallel surfaces are translated relative to one another to agitate the reagents during incubation to effect reagent mixing (such as the staining principles implemented on DAKO OMNIS slide stainers (Agilent)). In translating gap staining, a translatable head is positioned over the slide. A lower surface of the head is spaced apart from the slide by a first gap sufficiently small to allow a meniscus of liquid to form from liquid on the slide during translation of the slide. A mixing extension having a lateral dimension less than the width of a slide extends from the lower surface of the translatable head to define a second gap smaller than the first gap between the mixing extension and the slide. During translation of the head, the lateral dimension of the mixing extension is sufficient to generate lateral movement in the liquid on the slide in a direction generally extending from the second gap to the first gap. See WO 2011-139978 A1. It has recently been proposed to use inkjet technology to deposit reagents on slides. See WO 2016-170008 A1. This list of staining technologies is not intended to be comprehensive, and any fully or semi-automated system for performing biomarker staining may be used.

The staining methods are practiced on cellular samples of the suspected tissue, including tissue samples and cytological samples. In some embodiments, the cellular sample is obtained from a subject having or suspected of having a tumor. In some embodiments, the sample is obtained directly from a tumor. In some embodiments, the tumor is a solid tumor, such as a carcinoma, lymphoma, or sarcoma. In an embodiment, the tumor is a non-neuroendocrine tumor. In an embodiment, the non-neuroendocrine tumor is a solid tumor of the salivary gland, thyroid, skin, breast, head and/or neck, lung, upper gastrointestinal tract (including the esophagus and stomach), female reproductive system (including uterine, fallopian, and ovarian tumors), lower gastrointestinal tract (including the colon, rectal, and anal tumors), urogenital tract, exocrine, endocrine, renal, or of lymphocytic origin. In an embodiment, subject has a melanoma, salivary cancer, thyroid cancer, breast cancer, ovarian cancer, pancreatic cancer, head and neck cancer, lung cancer, esophageal cancer, gastric cancer (excluding gastrointestinal stromal tumors (GIST)), colorectal cancer (including cancer of the colon, rectum, and anus), prostate cancer, urothelial cancer, or lymphoma.

Where tissue samples are used, the tissue sample is processed in a manner compatible with histochemical staining, including, for example, fixation, embedding in a wax matrix (such as paraffin), and sectioning (such as with a microtome). No specific processing step is required by the present disclosure, so long as the sample obtained is compatible with histochemical staining of the sample with the set of biomarker-specific reagents. In a specific embodiment, microtome sections of formalin-fixed, paraffin-embedded (FFPE) samples are used in the staining process. Where cytological samples are used, the sample is fixed in formalin.

Depending on the biomarker-specific reagent being used and the sample being used, the sample may be subjected to an epitope retrieval process (also referred to as antigen retrieval) prior to application of the biomarker-specific reagent. Exemplary epitope retrieval processes include: heat-induced epitope retrieval (HIER), which involves heating the sample in various buffers at different pH levels; protease-based epitope retrieval (PBER), in which samples are digested by proteolytic enzymes prior to staining; and combinations of HIER and PBER. Various specific epitope retrieval processes are reviewed by Shi et al., D'Amico et al., Yamashita et al., Vinod et al., and Warford et al., although this is not exhaustive. Whether to perform epitope retrieval and the particular form of epitope retrieval to use depends on the specific biomarker-specific reagent selected, and may need to be empirically determined for each biomarker-specific reagent used.

Depending on the reagents and samples used, it may also be desirable to block activity of endogenous proteins prior to addition of biomarker-specific reagents and/or detection reagents. For example, where the detection reagents depend on biotin and biotin-binding proteins, it may be necessary to block endogenous biotin using, for example, free, unlabeled biotin-binding proteins. Likewise, many detection schemes rely on activity of enzymes, including phosphatases and peroxidases, which necessitates neutralization of endogenous enzymes having similar activities. Commercially-available kits are available for such blocking processes, e.g., Endogenous Biotin Blocking Kit (Cat. No. E21390, ThermoFisher Scientific), Endogenous Avidin/Biotin Blocking Kit (Cat. No. ab64212, Abcam, plc.), Endogenous Biotin Blocking Kit Cat. No. 760-050, Ventana Medical Systems, Inc.), Hydrogen Peroxide Blocking Reagent (Cat. No. ab64218, Abcam plc.), Peroxidase and Alkaline Phosphatase Blocking Reagent, (Code S2003, Agilent Technologies), among others.

It may also be useful to block sites on the sample to which the biomarker-specific reagent may bind non-specifically before applying the biomarker-specific reagent to the sample. Common blocking agents include buffered solutions of normal serum, non-fat dry milk, BSA (bovine serum albumin), and gelatin, as well as commercially available blocking agents such as eBioscience™ IHC/ICC Blocking Buffer—High Protein (Cat. No. 00-4952-54, ThermoFisher Scientific), eBioscience™ IHC/ICC Blocking Buffer—Low Protein (Cat. No. 00-4953-54, ThermoFisher Scientific), DISCOVERY antibody Block (Cat. No. 760-4204, Ventana Medical Systems, Inc.), among others.

Washing steps may be performed after each of these pre-processing steps by applying one or more passes of a wash buffer. Wash buffers typically are neutrally-buffered saline solutions, which may also contain small amounts of detergent. Exemplary wash buffers include, for example, Phosphate Buffered Saline (PBS), PBS-Tween20, Tris Buffered Saline (TBS), TBS-Tween20 (polysorbate 20), Tris-HCl, Tris-HC-Tween20, Phosphate Buffer (PB), AP Buffer, and the like.

Once the sample has been prepared for staining, the biomarker-specific reagent is applied to the sample and incubated for a sufficient period of time and under conditions to promote specific binding between the biomarker and the biomarker-specific reagent. A washing step may be performed after the sample is incubated with the biomarker-specific reagent by applying one or more passes of a wash buffer. This removes unbound or non-specifically bound biomarker-specific reagent from the sample to mitigate off-target and/or background staining.

Detection of the biomarker in the sample is achieved by depositing a detectable moiety in close proximity to the biomarker-specific reagent bound to the sample. In some embodiments, the detectable moiety is directly conjugated to the biomarker-specific reagent, and thus is deposited on the sample upon binding of the biomarker-specific reagent to its target (generally referred to as a direct labeling method). In other embodiments, deposition of the detectable moiety is effected by the applying a set of detection reagents to the sample after the application of the biomarker-specific reagent, wherein the detection reagents bind to or otherwise react with the biomarker-specific reagent in a manner the effects deposition of the detectable moiety (generally referred to as an indirect labeling method).

In some embodiments in which an indirect method is used, the detectable moiety is deposited via an enzymatic reaction localized to the biomarker-specific reagent. Suitable enzymes for such reactions are well-known and include, but are not limited to, oxidoreductases, hydrolases, and peroxidases. Specific enzymes explicitly included are horseradish peroxidase (HRP), alkaline phosphatase (AP), acid phosphatase, glucose oxidase, β-galactosidase, β-glucuronidase, and (3-lactamase. The enzyme may be directly conjugated to the biomarker-specific reagent, or may be indirectly associated with the biomarker-specific reagent via a labeling conjugate. As used herein, a “labeling conjugate” comprises:

-   -   (a) a specific detection reagent; and     -   (b) an enzyme conjugated to the specific detection reagent,         wherein the enzyme is reactive with a chromogenic substrate, a         signaling conjugate, and/or an enzyme-reactive dye under         appropriate reaction conditions to effect in situ generation of         the dye and/or deposition of the dye on the tissue sample.

In non-limiting examples, the specific detection reagent of the labeling conjugate may be a secondary detection reagent (such as a species-specific secondary antibody bound to a primary antibody, an anti-hapten antibody bound to a hapten-conjugated primary antibody, or a biotin-binding protein bound to a biotinylated primary antibody), a tertiary detection reagent (such as a species-specific tertiary antibody bound to a secondary antibody, an anti-hapten antibody bound to a hapten-conjugated secondary antibody, or a biotin-binding protein bound to a biotinylated secondary antibody), or other such arrangements. An enzyme thus localized to the sample-bound biomarker-specific reagent can then be used in a number of schemes to deposit a detectable moiety.

In some cases, the enzyme reacts with a chromogenic compound/substrate. Particular non-limiting examples of chromogenic compounds/substrates include 4-nitrophenylphospate (pNPP), fast red, bromochloroindolyl phosphate (BCIP), nitro blue tetrazolium (NBT), BCIP/NBT, fast red, AP Orange, AP blue, tetramethylbenzidine (TMB), 2,2′-azino-di-[3-ethylbenzothiazoline sulphonate] (ABTS), 4-chloronaphthol (4-CN), nitrophenyl-β-D-galactopyranoside (ONPG), o-phenylenediamine (OPD), 5-bromo-4-chloro-3-indolyl-β-galactopyranoside (X-Gal), methylumbelliferyl-β-D-galactopyranoside (MU-Gal), p-nitrophenyl-α-D-galactopyranoside (PNP), 5-bromo-4-chloro-3-indolyl-β-D-glucuronide (X-Gluc), 3-amino-9-ethyl carbazol (AEC), fuchsin, iodonitrotetrazolium (INT), tetrazolium blue, or tetrazolium violet.

In some embodiments, the enzyme can be used in a metallographic detection scheme. Metallographic detection methods include using an enzyme such as alkaline phosphatase in combination with a water-soluble metal ion and a redox-inactive substrate of the enzyme. In some embodiments, the substrate is converted to a redox-active agent by the enzyme, and the redox-active agent reduces the metal ion, causing it to form a detectable precipitate. (see, for example, U.S. patent application Ser. No. 11/015,646, filed Dec. 20, 2004, PCT Publication No. 2005/003777 and U.S. Patent Application Publication No. 2004/0265922; each of which is incorporated by reference herein in its entirety). Metallographic detection methods include using an oxido-reductase enzyme (such as horseradish peroxidase) along with a water soluble metal ion, an oxidizing agent and a reducing agent, again to for form a detectable precipitate. (See, for example, U.S. Pat. No. 6,670,113, which is incorporated by reference herein in its entirety).

In some embodiments, the enzymatic action occurs between the enzyme and the dye itself, wherein the reaction converts the dye from a non-binding species to a species deposited on the sample. For example, reaction of DAB with a peroxidase (such as horseradish peroxidase) oxidizes the DAB, causing it to precipitate.

In yet other embodiments, the detectable moiety is deposited via a signaling conjugate comprising a latent reactive moiety configured to react with the enzyme to form a reactive species that can bind to the sample or to other detection components. These reactive species are capable of reacting with the sample proximal to their generation, i.e. near the enzyme, but rapidly convert to a non-reactive species so that the signaling conjugate is not deposited at sites distal from the site at which the enzyme is deposited. Examples of latent reactive moieties include: quinone methide (QM) analogs, such as those described at WO2015124703A1, and tyramide conjugates, such as those described at, WO2012003476A2, each of which is hereby incorporated by reference herein in its entirety. In some examples, the latent reactive moiety is directly conjugated to a dye, such as N,N′-biscarboxypentyl-5,5′-disulfonato-indo-dicarbocyanine (Cy5), 4-(dimethylamino) azobenzene-4′-sulfonamide (DABSYL), tetramethylrhodamine (DISCO Purple), and Rhodamine 110 (Rhodamine). In other examples, the latent reactive moiety is conjugated to one member of a specific binding pair, and the dye is linked to the other member of the specific binding pair. In other examples, the latent reactive moiety is linked to one member of a specific binding pair, and an enzyme is linked to the other member of the specific binding pair, wherein the enzyme is (a) reactive with a chromogenic substrate to effect generation of the dye, or (b) reactive with a dye to effect deposition of the dye (such as DAB). Examples of specific binding pairs include:

-   -   (1) a biotin or a biotin derivative (such as desthiobiotin)         linked to the latent reactive moiety, and a biotin-binding         entity (such as avidin, streptavidin, deglycosylated avidin         (such as NEUTRAVIDIN), or a biotin binding protein having a         nitrated tyrosine at its biotin binding site (such as         CAPTAVIDIN)) linked to a dye or to an enzyme reactive with a         chromogenic substrate or reactive with a dye (for example, a         peroxidase linked to the biotin-binding protein when the dye is         DAB); and     -   (2) a hapten linked to the latent reactive moiety, and an         anti-hapten antibody linked to a dye or to an enzyme reactive         with a chromogenic substrate or reactive with a dye (for         example, a peroxidase linked to the biotin-binding protein when         the dye is DAB).         Non-limiting examples of biomarker-specific reagent and         detection reagent combinations are set forth in Table 4 are         specifically included.

TABLE 4 A. Biomarker-specific reagent linked directly to detectable moiety Biomarker-specific reagent-Dye conjugate B. Biomarker-specific reagent linked to enzyme reacting with detectable moiety Biomarker-specific reagent-Enzyme conjugate + DAB Biomarker-specific reagent-Enzyme conjugate + Chromogen Biomarker-specific reagent-Enzyme conjugate + Fluorophore C. Biomarker-specific reagent linked to Enzyme reacting with detectable moiety C1. Signaling conjugate Biomarker-specific reagent-Enzyme comprises detectable moiety conjugate + QM-Dye conjugate Biomarker-specific reagent-Enzyme conjugate + Tyramide-Dye conjugate C2. Signaling conjugate Biomarker-specific reagent-Enzyme comprises enzyme that reacts conjugate + QM-Enzyme conjugate + directly with detectable DAB moiety Biomarker-specific reagent-Enzyme conjugate + QM-Enzyme conjugate + Chromogen Biomarker-specific reagent-Enzyme conjugate + QM-Enzyme conjugate + Fluorophore Biomarker-specific reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + DAB Biomarker-specific reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Chromogen Biomarker-specific reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Fluorophore C3. Signaling conjugate Biomarker-specific reagent-Enzyme comprises enzyme that reacts conjugate + QM-Enzyme conjugate + with second signaling QM-Dye conjugate conjugate comprising Biomarker-specific reagent-Enzyme detectable moiety conjugate + QM-Enzyme conjugate + Tyramide-Dye conjugate Biomarker-specific reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + QM-Dye conjugate Biomarker-specific reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Tyramide-Dye conjugate C4. Signaling conjugate Biomarker-specific reagent-Enzyme comprises member of a conjugate + Tyramide-(biotin or hapten) specific binding pair and conjugate + Dye-(avidin or anti-hapten other member of binding pair specific detection reagent) conjugate is linked to detectable moiety Biomarker-specific reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Dye-(avidin or anti-hapten specific detection reagent) conjugate C5. Signaling conjugate Biomarker-specific reagent-Enzyme comprises member of a conjugate + QM-(biotin or hapten) specific binding pair and conjugate + Enzyme-(avidin or other member of binding pair anti-hapten specific detection reagent) is linked to enzyme reactive conjugate + DAB with detectable moiety Biomarker-specific reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore Biomarker-specific reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + DAB Biomarker-specific reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore C6. Signaling conjugate Biomarker-specific reagent-Enzyme comprises member of a conjugate + QM-(biotin or hapten) specific binding pair and conjugate + Enzyme-(avidin or other member of binding pair anti-hapten specific detection reagent) is linked to enzyme reactive conjugate + Tyramide-Dye conjugate with second detectable Biomarker-specific reagent-Enzyme moiety linked to a detectable conjugate + QM-(biotin or hapten) moiety conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Tyramide-Dye conjugate Biomarker-specific reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate D. Biomarker-specific reagent linked to member of specific binding pair D1. Dye linked to other Biomarker-specific reagent-(biotin or member of specific binding hapten) conjugate + Dye-(avidin or pair anti-hapten specific detection reagent) conjugate D2. Enzyme linked to other Biomarker-specific reagent-(biotin or member of specific binding hapten) conjugate + Enzyme-(avidin or pair, wherein the enzyme is anti-hapten specific detection reagent) reactive with detectable conjugate + DAB moiety Biomarker-specific reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + fluorophore Biomarker-specific reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Tyramide-Dye conjugate E. Secondary detection reagent linked directly to detectable moiety Biomarker-specific reagent + 2° specific detection reagent-Dye conjugate F. Secondary detection reagent linked to Enzyme reacting with detectable moiety Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Fluorophore G. Secondary detection reagent linked to Enzyme reacting with detectable moiety G1. Signaling conjugate Biomarker-specific reagent + 2° specific comprises detectable moiety detection reagent-Enzyme conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Dye conjugate G2. Signaling conjugate Biomarker-specific reagent + 2° specific comprises enzyme that reacts detection reagent-Enzyme conjugate + directly with detectable QM-Enzyme conjugate + DAB moiety Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-Enzyme conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Fluorophore G3. Signaling conjugate Biomarker-specific reagent + 2° specific comprises enzyme that reacts detection reagent-Enzyme conjugate + with second signaling QM-Enzyme conjugate + QM-Dye conjugate comprising conjugate detectable moiety Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-Enzyme conjugate + Tyramide-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Tyramide-Dye conjugate G4. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent-Enzyme conjugate + specific binding pair and Tyramide-(biotin or hapten) conjugate + other member of binding pair Dye-(avidin or anti-hapten specific is linked to detectable moiety detection reagent) conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Dye-(avidin or anti-hapten specific detection reagent) conjugate G5. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent-Enzyme conjugate + specific binding pair and QM-(biotin or hapten) conjugate + other member of binding pair Enzyme-(avidin or anti-hapten specific is linked to enzyme reactive detection reagent) conjugate + DAB with detectable moiety Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Flurophore G6. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent-Enzyme conjugate + specific binding pair and QM-(biotin or hapten) conjugate + other member of binding pair Enzyme-(avidin or anti-hapten specific is linked to enzyme reactive detection reagent) conjugate + Tyramide- with second detectable Dye conjugate moiety linked to a detectable Biomarker-specific reagent + 2° specific moiety detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Tyramide- Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-Enzyme conjugate + Tyramide-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate H. Secondary detection reagent linked to member of specific binding pair H1. Dye linked to other Biomarker-specific reagent + 2° specific member of specific binding detection reagent-(biotin or hapten) pair conjugate + Dye-(avidin or anti-hapten specific detection reagent) conjugate H2. Enzyme linked to Biomarker-specific reagent + 2° specific other member of specific detection reagent-(biotin or hapten) binding pair, wherein the conjugate + Enzyme-(avidin or enzyme is reactive with anti-hapten specific detection reagent) detectable moiety conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Tyramide-Dye conjugate I. Tertiary specific detection reagent linked directly to detectable moiety Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Dye conjugate J. Tertiary specific detection reagent linked to Enzyme reacting with detectable moiety Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Fluorophore K. Tertiary specific detection reagent linked to Enzyme reacting with detectable moiety K1. Signaling conjugate Biomarker-specific reagent + 2° specific comprises detectable moiety detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- Dye conjugate K2. Signaling conjugate Biomarker-specific reagent + 2° specific comprises enzyme that reacts detection reagent + 3° specific detection directly with detectable reagent-Enzyme conjugate + moiety QM-Enzyme conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-Enzyme conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- Enzyme conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide-Enzyme conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- Enzyme conjugate + Fluorophore K3. Signaling conjugate Biomarker-specific reagent + 2° specific comprises enzyme that reacts detection reagent + 3° specific detection with second signaling reagent-Enzyme conjugate + QM- conjugate comprising Enzyme conjugate + QM-Dye conjugate detectable moiety Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM- Enzyme conjugate + Tyramide-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- Enzyme conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- Enzyme conjugate + Tyramide-Dye conjugate K4. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent + 3° specific detection specific binding pair and reagent-Enzyme conjugate + Tyramide- other member of binding pair (biotin or hapten) conjugate + Dye- is linked to detectable moiety (avidin or anti-hapten specific detection reagent) conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Dye-(avidin or anti-hapten specific detection reagent) conjugate K5. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent + 3° specific detection specific binding pair and reagent-Enzyme conjugate + QM-(biotin other member of binding pair or hapten) conjugate + Enzyme-(avidin is linked to enzyme reactive or anti-hapten specific detection reagent) with detectable moiety conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + QM-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + Fluorophore K6. Signaling conjugate Biomarker-specific reagent + 2° specific comprises member of a detection reagent + 3° specific detection specific binding pair and reagent-Enzyme conjugate + QM-(biotin other member of binding pair or hapten) conjugate + Enzyme-(avidin is linked to enzyme reactive or anti-hapten specific detection reagent) with second detectable conjugate + Tyramide-Dye conjugate moiety linked to a detectable Biomarker-specific reagent + 2° specific moiety detection reagent + 3° specific detection reagent-Enzyme conjugate + QM- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + Tyramide-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-Enzyme conjugate + Tyramide- (biotin or hapten) conjugate + Enzyme- (avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate L. Tertiary specific detection reagent linked to member of specific binding pair L1. Dye linked to other Biomarker-specific reagent + 2° specific member of specific binding detection reagent + 3° specific detection pair reagent-(biotin or hapten) conjugate + Dye-(avidin or anti-hapten specific detection reagent) conjugate L2. Enzyme linked to Biomarker-specific reagent + 2° specific other member of specific detection reagent + 3° specific detection binding pair, wherein the reagent-(biotin or hapten) conjugate + enzyme is reactive with Enzyme-(avidin or anti-hapten specific detectable moiety detection reagent) conjugate + DAB Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Chromogen Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Fluorophore Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + QM-Dye conjugate Biomarker-specific reagent + 2° specific detection reagent + 3° specific detection reagent-(biotin or hapten) conjugate + Enzyme-(avidin or anti-hapten specific detection reagent) conjugate + Tyramide- Dye conjugate In a specific embodiment, the biomarker-specific reagents and the specific detection reagents set forth in Table 4 are antibodies. As would be appreciated by a person having ordinary skill in the art, the detection scheme for each of the biomarker-specific reagent may be the same, or it may be different.

Non-limiting examples of commercially available detection reagents or kits comprising detection reagents suitable for use with present methods include: VENTANA ultraView detection systems (secondary antibodies conjugated to enzymes, including HRP and AP); VENTANA iVIEW detection systems (biotinylated anti-species secondary antibodies and streptavidin-conjugated enzymes); VENTANA OptiView detection systems (OptiView) (anti-species secondary antibody conjugated to a hapten and an anti-hapten tertiary antibody conjugated to an enzyme multimer); VENTANA Amplification kit (unconjugated secondary antibodies, which can be used with any of the foregoing VENTANA detection systems to amplify the number of enzymes deposited at the site of primary antibody binding); VENTANA OptiView Amplification system (Anti-species secondary antibody conjugated to a hapten, an anti-hapten tertiary antibody conjugated to an enzyme multimer, and a tyramide conjugated to the same hapten. In use, the secondary antibody is contacted with the sample to effect binding to the primary antibody. Then the sample is incubated with the anti-hapten antibody to effect association of the enzyme to the secondary antibody. The sample is then incubated with the tyramide to effect deposition of additional hapten molecules. The sample is then incubated again with the anti-hapten antibody to effect deposition of additional enzyme molecules. The sample is then incubated with the detectable moiety to effect dye deposition); VENTANA DISCOVERY, DISCOVERY OmniMap, DISCOVERY UltraMap anti-hapten antibody, secondary antibody, chromogen, fluorophore, and dye kits, each of which are available from Ventana Medical Systems, Inc. (Tucson, Ariz.); PowerVision and PowerVision+ IHC Detection Systems (secondary antibodies directly polymerized with HRP or AP into compact polymers bearing a high ratio of enzymes to antibodies); and DAKO EnVision™+ System (enzyme labeled polymer that is conjugated to secondary antibodies).

If desired, the biomarker-stained slides may be counterstained to assist in identifying morphologically relevant areas. Examples of counterstains include chromogenic nuclear counterstains, such as hematoxylin (stains from blue to violet), Methylene blue (stains blue), toluidine blue (stains nuclei deep blue and polysaccharides pink to red), nuclear fast red (also called Kernechtrot dye, stains red), and methyl green (stains green); non-nuclear chromogenic stains, such as eosin (stains pink); fluorescent nuclear stains, including 4′, 6-diamino-2-pheylindole (DAPI, stains blue), propidium iodide (stains red), Hoechst stain (stains blue), nuclear green DCS1 (stains green), nuclear yellow (Hoechst 5769121, stains yellow under neutral pH and stains blue under acidic pH), DRAQ5 (stains red), DRAQ7 (stains red); fluorescent non-nuclear stains, such as fluorophore-labelled phalloidin, (stains filamentous actin, color depends on conjugated fluorophore).

III. Staining Evaluation

In an embodiment, a set of stained samples generated by the presently disclosed methods are used to determine the presence or absence of a fusion protein in a patient sample. In the typical case, a sample obtained from a patient and prepared for analysis as set forth above. One portion of the sample (for example, a first tissue section of a biopsy of tumor resection sample, or a first slide prepared from a cytological sample of tumor cells (such as cellular smears (such as cervical smears), fine needle aspirates, isolated circulating tumor cells and the like) are prepared and stained with the biomarker-specific reagent. The stained samples are then scored for the percentage of cells staining and/or the percentage of cells staining at or above a pre-determined threshold level. Preferably, the samples are fixed in a formalin solution. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is in the range of 25% to 75%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 50%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 60%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 75%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is in the range of 25% to 75%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 50%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 60%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 75%.

In some cases, the stained samples are stratified on the basis of expression pattern and then scored with a scoring methodology specific to the staining pattern. For example, where fixation gradients are observed, a first scoring methodology is applied to samples having a cytoplasmic and/or membranous expression pattern, and a second scoring methodology is applied to samples having a nuclear cellular localization. For example, samples having a cytoplasmic and/or membranous staining pattern may be scored by determining whether the sample meets or exceeds a threshold level of tumor cells at or above a threshold staining intensity, which are considered to be TRK fusion protein positive. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is in the range of 25% to 75%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 50%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 60%. In an embodiment, the threshold staining intensity is at least 1.5+ and the threshold level of tumor cells having the threshold staining intensity is 75%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is in the range of 25% to 75%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 50%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 60%. In an embodiment, the threshold staining intensity is at least 2+ and the threshold level of tumor cells having the threshold staining intensity is 75%.

As another example, samples having a nuclear staining pattern may be scored by determining whether a minimum contiguous tumor cell area of the sample has a concentration of tumor cells staining at or above a threshold expression level. In an embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is in the range of 25% to 75% or 25% to 80%. In another embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is at least 75%. In another embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is at least 80%. In an embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is in the range of 25% to 75% or 25% to 80%. In another embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is at least 75%. In another embodiment, the threshold contiguous tumor cell area is at least 20 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is at least 80%. In an embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is in the range of 25% to 75% or 25% to 80%. In another embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is at least 75%. In another embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is any specific staining over background, and the threshold percentage of cells is at least 80%. In an embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is in the range of 25% to 75% or 25% to 80%. In another embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is at least 75%. In another embodiment, the threshold contiguous tumor cell area is at least 50 cells, the threshold stain intensity is ≥0.5+, and the threshold percentage of cells is at least 80%.

VI. Clinical Application

In an embodiment, the assay as described herein is used to characterize a tumor sample from a patient. For example, a biopsy section or a resection sample is obtained, fixed, embedded in paraffin, sectioned, and stained. Stained sections are scored as described above. In some embodiments, a tumor having a score indicative of the presence of a fusion protein is characterized as “fusion positive,” while a tumor having a score that is not indicative of the presence of a fusion protein is characterized as “fusion negative.” In other embodiments, an intermediate category of cells between “fusion positive” and “fusion negative” is characterized as “equivocal.” For example, where the scoring methodology is based on a threshold percentage of cells staining at or above a threshold level, a range of percentages below the threshold percentage may be defined as “equivocal,” and all other samples having a percentage of cells falling below the equivocal range are deemed “fusion negative.” As another example, where the scoring methodology is based on a threshold percentage of cells staining at or above a threshold level within a threshold tumor cell area, a range of percentages below the threshold tumor cell area may be defined as “equivocal,” and all other samples having a percentage of cells falling below the equivocal range are deemed “fusion negative.”

In some embodiments, the assay is used as a screening test to identify patients eligible for a nucleic acid-based assay to confirm the presence of the fusion protein. For example, samples may be screened for the presence or absence of a fusion protein using the assay, and only those samples that are characterized as fusion positive are subjected to a sequencing-based or PCR-based assay to confirm the presence and/or identity of the fusion that is was detected in the assay. In other embodiments, the assay is a reflex test to confirm the presence and expression of a fusion protein identified by a nucleic acid-based assay. For example, samples may be screened for the presence or absence of a NTRK gene rearrangement using a sequencing-based or PCR-based assay, and only those samples that are characterized as rearrangement-positive by the sequencing-based or PCR-based assay are screened by the assay described herein to confirm the presence and/or expression of the fusion detected by the nucleic acid assay. In other embodiments, characterization of the presence or absence of a fusion protein is made solely on the basis of the assay. In yet other embodiments, samples characterized as “fusion negative” or “equivocal” may be screened for the presence of an NTRK gene rearrangement by a sequencing-based or PCR-based assay, and cells that are characterized as “fusion positive” are not.

In some embodiments, the assay is used to select a therapy for the patient. For example, a patient having a tumor or sample characterized as “fusion positive” receives a targeted therapy directed against the wild-type counterpart, optionally in combination with a standard treatment course for the tumor. Exemplary targeted therapies include those recited in Table 5:

TABLE 5 Drug type Exemplary active ingredients or compound class Small molecule tyrosine aliratinib; belizatinib; cabozantinib; dovitinib; kinase inhibitor DS-6052B; entrectinib; F17752; LOXO-101 (larotrectinib); milciclib; PLX7486; sitrivatinib A patient having a tumor or sample characterized as fusion negative receives a standard therapy, without inclusion of a targeted therapy for the wild-type counterpart.

VIII. Examples

To assess whether a scoring algorithm could be developed that could predict the presence of Trk fusions across tumor types, IHC staining and analysis of greater than 3000 tissues across multiple indications was conducted.

Formalin-fixed, paraffin-embedded (FFPE) normal and neoplastic tissues were commercially acquired. Tissues were screened with a prototype IHC assay with a pan-TRK antibody clone EPR17341, comprising heat induced epitope retrieval followed by antibody incubation and colormetric development using OptiView DAB Detection (RTD, Tucson, Ariz.) on a BenchMark ULTRA automated slide stainer (RTD, Tucson Ariz.).

A subset of cases, the majority having specific staining by the pan-TRK (EPR17341) assay, were further evaluated with in situ hybridization (ISH) with break-apart probes for NTRK1, 2 and 3. The NTRK1, 2, and 3 Break-Apart Oligo Probes each consist of two pools of oligonucleotides (oligos) targeting the genomic regions across the 5′ and 3′ ends of the NTRK1, 2, and 3 genes. DNP and Fluorescein haptens were attached to oligos in a basic insertion configuration during synthesis using DNP-TEG phosphoramidite (Link Technologies Ltd, Bellshill, Lanarkshire) and 6-fluorescein phosphoramidite (Link Technologies Ltd, Bellshill, Lanarkshire). Synthesized oligos were purified using reverse-phase cartridges and mass spectrometry was performed to verify removal of truncated oligos.

Criteria used to define break-apart status for the ISH assays were determined based on evaluation of average break-apart rates in normal tissues and in tumors without pan-TRK IHC expression. Tumors in which break-apart rates were greater than 5 standard deviations above the average were considered to represent true NTRK gene fusions.

Representative images of pan-TRK staining across different tumor types with various genotypes are shown in FIGS. 2A-2B. 9% (n=324) of tumors demonstrated specific pan-TRK IHC staining when defined as >0% of tumor cell staining (range: 0%-54% in gastric cancers and salivary gland cancers, respectively). The overall percentage of cases with specific staining decreased to 5% (n=191) and 4% (n=133) when only considering specimens with IHC specific staining in ≥10% and ≥25% of tumor cells, respectively.

164 cases demonstrating any staining by IHC were available for ISH testing. Of these, 12 were found to harbor NTRK fusions (5 CRC, 2 melanoma, 2 papillary thyroid cancers, 2 salivary gland cancers and 1 pancreatic cancer). The rate of pan-TRK positive cases at various tumor cell staining percentages by tumor type including results of confirmatory testing by ISH is shown at Table 6:

TABLE 6 No Tumor stain >0% >1% >5% >10% >25% >50% >75% A B C D PC (162)  95%  5%  5%  5%  5%  3%  1%  1% 8 1 1 100% CRC (208)  94%  6%  6%  4%  3%  2%  2%  2% 13 7 5  71% MN (444)  96%  4%  4%  2%  2%  1%  1%  0% 19 6 2  33% PTT (111)  89% 11% 11% 11% 11% 10%  8%  7% 12 6 2  33% SGT (61)  46% 54% 54% 44% 44% 33% 18%  3% 33 8 0  25% CAC (155)  98%  2%  0%  0%  0%  0%  0%  0% 3 3 0  0% HCC (95)  97%  3%  3%  2%  2%  1%  0%  0% 3 3 0  0% UC (131)  96%  4%  3%  3%  3%  2%  0%  0% 5 5 0  0% NSCLC  93%  7%  6%  4%  3%  2%  1%  0% 97 64 0  0% (1366) Breast  90% 10%  8%  6%  5%  3%  2%  1% 42 15 0  0% (421) HNSCC  82% 18% 17% 10% 10%  6%  4%  0% 22 11 0  0% (125) GB (18)  78% 22% 22% 17% 17% 11% 11%  0% 4 1 0  0% SCN (130)  77% 23% 21% 18% 17% 16% 13%  9% 32 18 0  0% NET (53)  47% 53% 51% 49% 43% 36% 30% 13% 29 16 0  0% GC (31) 100%  0%  0%  0%  0%  0%  0%  0% 0 0 0 PC (12) 100%  0%  0%  0%  0%  0%  0%  0% 0 0 0 RCC (20)  95%  5%  5%  5%  5%  5%  5%  0% 1 0 0 EOC (12)  92%  8%  8%  0%  0%  0%  0%  0% 1 0 0 PC = Pancreatic cancer; CRC = colorectal cancer; PTT = Papillary Thyroid Tumor; MN = Melanoma; SGT = Salivary Gland Tumor; CAC = Cholangiocarcinoma; HCC = Hepatocellular carcinoma; UC = Urothelial Carcinoma; NSCLC = Non-small cell lung carcinoma; HNSCC = Head and neck squamous cell carcinoma; GB = Glioblastoma; SCN = Spindle Cell Neoplasm (including GIST); NET = Neuroendocrine Tumors; GC = Gastric Carcinoma; PC = Prostatic Carcinoma; RCC = Renal cell carcinoma; EOC = Epithelial Ovarian Carcinoma; A = # IHC positive; B = # tested by ISH; C = # fusion positive by ISH; D = % IHC + confirmed as fusion+

Intensity of staining and percent tumor cells staining varied by tissue type but cases found to harbor fusions tended to have higher intensity staining and a greater percentage of tumor cells staining (see FIGS. 3A & 3B). FIGS. 3A and 3B show the distribution of ISH-confirmed samples by percentage of tumor cells staining (0-100%) and by intensity of the staining (0-3+). Circles depict fusion-negative cases while triangles represent fusion-positive cases. Colors represent various tumor histologies. FIG. 3A shows the staining distribution of tumor types with ISH-confirmed fusion-positive cases in the dataset and FIG. 3B shows the staining distribution of neuroendocrine tumors where no fusion-positive cases were detected.

Results by percent of tumor cells staining by IHC in all tumors in the dataset are shown at Table 7:

TABLE 7 % tumor % Positive cases cells Available Positive positive not detected staining Positive for ISH by by IHC at this IHC by IHC IHC confirmation ISH and ISH percentage  >0% 324 164 12  7.3% NA  >1% 288 139 12  8.6% NA  >5% 222 133 12  9.0% NA >10% 191 122 10  8.2% Melanoma >25% 133  88 10 11.4% Melanoma >50%  91  56  9 16.1% Melanoma, pancreas >75%  45  34  7 20.6% Melanoma (2), pancreas, PTC and salivary gland

12/164 (7%) of cases, for which the IHC specific staining was >0% of tumor cells, demonstrated the presence of an NTRK fusion by ISH. 10/88 (11%) of cases, for which IHC specific staining was >25% of tumor cells, demonstrated presence of fusion by ISH (Table 6). Tumors showing fusions by ISH tended to stain at higher intensity and higher tumor percentage by pan-TRK IHC (upper right-hand quadrant; FIG. 3A) than did non-fusion tumors, the exception being neuroendocrine tumors (FIG. 3B). Using the higher definition of IHC specific positive staining (>25%) would have resulted in two fusion-positive melanomas being excluded from ISH testing (Table 6). These two tissue samples stained poorly by IHC, demonstrating evidence of fixation gradients. Importantly, these tissues did exhibit nuclear staining of high intensity in areas that were not affected by fixation-related artifact, in a high percentage (>90%) of contiguous cells.

A sub-categorization of solid tumors based on IHC and ISH testing is illustrated at FIG. 4.

Examples of staining patterns observed are illustrated at FIG. 5 and FIG. 6. As shown at FIG. 5, staining patterns could include aspect of membranous staining (A), cytoplasmic staining (A-C) and nuclear staining (C). FIG. 7 shows that some samples experienced fixation gradients, which could affect staining levels of some cells. It was noted that samples with nuclear localization were more sensitive to fixation gradients than samples having a cytoplasmic/membrane localization.

In sum, pan-TRK IHC staining varies in both intensity and in percentage of tumor cells staining across tumor types. Solid tumors harboring fusions based on ISH showed IHC staining with higher intensity and in a greater percentage of tumor cells than did tumors with wild-type TRK protein expression, with the exception of neuroendocrine and spindle cell tumors. In tumor types with low prevalence of wild-type TRK protein expression (e.g. CRC and papillary thyroid cancer) pan-TRK IHC staining may be useful in helping to identifying tumors harboring fusions. By contrast, in tumors with high prevalence of wild-type TRK protein expression (e.g. neuroendocrine tumors, GIST) the distribution of IHC staining percentage and intensity did not support clear differentiation between wild-type expression and fusion. Per Table 6, as the percentage of tumor cell staining with pan-TRK IHC increased, the number of specimens (out of the total 164 cases) that were subjected to ISH progressively decreased; this decrease, however, did not compromise identification of tumors with NTRK gene fusion by ISH in well-preserved tissues. This metric, combined with increased IHC staining intensity seem to further highlight those tumors with NTRK gene fusion by ISH testing.

Two melanomas and one pancreatic ductal adenocarcinoma did not follow the above observations. The observed lower percentages of tumor cell staining were likely related to fixation artifacts. Interestingly however, small areas of contiguous viable tumor did demonstrate high percentages of nuclear staining at high intensity.

VI. Additional Disclosed Embodiments

The following exemplary embodiments shall be included as part of this disclosure:

Embodiment 1. A method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample, the method comprising:

-   -   affinity histochemically staining the sample with a         biomarker-specific reagent that specifically binds to one or         more of: an amino acid sequence comprising, consisting         essentially of, or consisting of residues 363-760 of SEQ ID NO:         1; an amino acid sequence comprising, consisting essentially of,         or consisting of residues 646-838 of SEQ ID NO: 2; or an amino         acid sequence comprising, consisting essentially of, or         consisting of residues 718-839 of SEQ ID NO: 3;     -   detecting a staining pattern in the sample; and     -   scoring the sample as positive for a fusion protein involving         TrkA, TrkB, or TrkC if the sample has a staining pattern in         which greater than or equal to a threshold percentage of tumor         cells stain above a threshold specific staining intensity.

Embodiment 2. The method of Embodiment 1, wherein the percentage of tumor cells staining above the threshold specific staining intensity is a percentage of tumor cells in the entire tumor area.

Embodiment 3. The method of any one of Embodiments 1 and 2, wherein the threshold percentage of tumor cells is in the range of 50% to 75% and the threshold staining intensity is at least 1.5.

Embodiment 4. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is 1.75.

Embodiment 5. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is 1.75.

Embodiment 6. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is 1.75.

Embodiment 7. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is 2.

Embodiment 8. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is 2.

Embodiment 9. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is 2.

Embodiment 10. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is 3.

Embodiment 11. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is 3.

Embodiment 12. The method of Embodiment 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is 3.

Embodiment 13. The method of any one of Embodiments 2 to 12, wherein the sample has a membranous and/or cytoplasmic staining pattern.

Embodiment 14. The method of any one of Embodiments 1 to 13, wherein the percentage of tumor cells staining above the threshold specific staining intensity is a percentage of tumor cells within a tumor cell area having a threshold level of contiguous tumor cells.

Embodiment 15. The method of Embodiment 14, wherein the threshold level of contiguous tumor cells is at least 20 contiguous cells, the threshold percentage of cells is in the range of 20% to 90%, and the threshold staining intensity is any specific staining above background.

Embodiment 16. The method of Embodiment 14, wherein the threshold level of contiguous tumor cells is at least 20 contiguous cells, the threshold percentage of cells is in the range of 20% to 90%, and the threshold staining intensity is 0.5.

Embodiment 17. The method of Embodiment 14, wherein the threshold level of contiguous tumor cells is at least 50 contiguous cells and the threshold percentage of cells is at least 80%, and the threshold staining intensity is any specific staining above background.

Embodiment 18. The method of Embodiment 14, wherein the threshold level of contiguous tumor cells is at least 50 contiguous cells and the threshold percentage of cells is at least 80%, and the threshold staining intensity is 0.5.

Embodiment 19. The method of any one of Embodiments 14 to 18, wherein the sample has a nuclear staining pattern.

Embodiment 20. A method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample, the method comprising:

-   -   affinity histochemically staining the sample with a         biomarker-specific reagent that specifically binds to one or         more of: an amino acid sequence comprising, consisting         essentially of, or consisting of residues 363-760 of SEQ ID NO:         1; an amino acid sequence comprising, consisting essentially of,         or consisting of residues 646-838 of SEQ ID NO: 2; or an amino         acid sequence comprising, consisting essentially of, or         consisting of residues 718-839 of SEQ ID NO: 3;     -   detecting staining pattern in the sample; and     -   scoring the sample as positive for a fusion protein involving         TrkA, TrkB, or TrkC if:         -   the sample has a cytoplasmic and/or membranous staining             pattern and has a greater than or equal to a first threshold             percentage of tumor cells staining above a first threshold             staining intensity; or         -   the sample has a nuclear staining pattern and greater than             or equal to a second threshold percentage of cells within a             threshold tumor cell area that are specifically stained at a             second staining intensity.

Embodiment 21. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is in the range of 50% to 75% and the first threshold staining intensity is at least 1.5.

Embodiment 22. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 50% and the first threshold staining intensity is 1.75.

Embodiment 23. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 60% and the first threshold staining intensity is 1.75.

Embodiment 24. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 75% and the first threshold staining intensity is 1.75.

Embodiment 25. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 50% and the first threshold staining intensity is 2.

Embodiment 26. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 60% and the first threshold staining intensity is 2.

Embodiment 27. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 75% and the first threshold staining intensity is 2.

Embodiment 28. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 50% and the first threshold staining intensity is 3.

Embodiment 29. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 60% and the first threshold staining intensity is 3.

Embodiment 30. The method of Embodiment 20, wherein the first threshold percentage of tumor cells is 75% and the first threshold staining intensity is 3.

Embodiment 31. The method of Embodiment 20, wherein the threshold tumor cell area is at least 20 contiguous cells, the second threshold percentage of cells is in the range of 20% to 90%, and the second threshold staining intensity is any specific staining above background.

Embodiment 32. The method of Embodiment 20, wherein the threshold tumor cell area is at least 20 contiguous cells, the second threshold percentage of cells is in the range of 20% to 90%, and the second threshold staining intensity is 0.5.

Embodiment 33. The method of Embodiment 20, wherein the threshold tumor cell area is at least 50 contiguous cells and the second threshold percentage of cells is at least 80%, and the second threshold staining intensity is any specific staining above background.

Embodiment 33. The method of Embodiment 20, wherein the threshold tumor cell area is at least 50 contiguous cells and the second threshold percentage of cells is at least 80%, and the second threshold staining intensity is 0.5.

Embodiment 34. The method of any one of Embodiments 1 to 33, wherein the biomarker-specific reagent specifically binds to: an amino acid sequence comprising, consisting essentially of, or consisting of residues 363-760 of SEQ ID NO: 1; an amino acid sequence comprising, consisting essentially of, or consisting of residues 646-838 of SEQ ID NO: 2; and an amino acid sequence comprising, consisting essentially of, or consisting of residues 718-839 of SEQ ID NO: 3.

Embodiment 35. The method of Embodiment 34, wherein the biomarker-specific reagent is an antibody.

Embodiment 36. The method of Embodiment 35, wherein the antibody is immunospecific for an epitope disposed in an amino acid sequence consisting of amino acids 816-838 of SEQ ID NO: 2.

Embodiment 37. The method of Embodiment 36, wherein the antibody is monoclonal antibody clone EPR17341.

Embodiment 38. The method of any one of Embodiments 34 to 37, wherein the affinity histochemically staining comprises:

-   -   (a) subjecting the sample to a heat-induced epitope retrieval         process; and     -   (b) contacting the sample with the biomarker-specific reagent         and a set of detection reagents to deposit a brightfield dye in         proximity to any biomarker-specific reagent bound to the sample.

Embodiment 39. The method of Embodiment 38, wherein (b) is a biomarker-specific reagent and detection reagent combination as set forth in Table 4.

Embodiment 40. The method of Embodiment 38, wherein:

-   -   (b1) the biomarker specific reagent is an antibody that is         specifically immunoreactive with each of: an amino acid sequence         consisting of residue 363-760 of SEQ ID NO: 1; an amino acid         sequence consisting of residues 646-838 of SEQ ID NO: 2; and an         amino acid sequence consisting of residues 718-839 of SEQ ID NO:         3; and     -   (b2) the set of detection reagents comprises a secondary         antibody immunoreactive with the antibody of (b1), a tertiary         antibody immunoreactive with the secondary antibody conjugated         to an enzyme, and a set of reagents reactive with the enzyme to         effect deposition of a brightfield dye on the sample.

Embodiment 41. The method of Embodiment 38, wherein the secondary antibody is haptenated and the tertiary antibody is an anti-hapten antibody.

Embodiment 42. The method of Embodiment 41, wherein the brightfield dye is 3,3′-diaminobenzidine (DAB).

Embodiment 43. A method of detecting an NTRK rearrangement in a non-neuroendocrine tumor sample, the method comprising detecting the presence of a Trk fusion protein in the sample according to the method of any one of Embodiments 1 to 42, and screening the sample for the NTRK rearrangement by sequencing, reverse transcriptase polymerase chain reaction, or in situ hybridization if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC.

Embodiment 44. A method of detecting an NTRK rearrangement in a non-neuroendocrine tumor sample, the method comprising detecting the presence of a Trk fusion protein in the sample according to the method of any one of Embodiments 1 to 42, identifying samples as either Trk Fusion Positive or Trk Fusion Negative, and screening samples that are Trk Fusion Negative for the NTRK rearrangement by sequencing, reverse transcriptase polymerase chain reaction, or in situ hybridization.

Embodiment 45. A method of detecting an NTRK rearrangement in a non-neuroendocrine tumor sample, the method comprising detecting the presence of a Trk fusion protein in the sample according to the method of any one of Embodiments 1 to 42, identifying samples as either Trk Fusion Positive, Trk Fusion Equivocal, or Trk Fusion Negative, and screening samples that are Trk Fusion Equivocal for the NTRK rearrangement by sequencing, reverse transcriptase polymerase chain reaction, or in situ hybridization.

Embodiment 46. A method of selecting a patient to receive a Trk-directed therapy, comprising detecting the presence of a Trk fusion protein in a non-neuroendocrine tumor sample according to a method of any one of Embodiments 1 to 43, and selecting the patient to receive the therapy if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC or the NTRK rearrangement is detected.

Embodiment 47. A method of selecting a patient to receive a Trk-directed therapy, comprising detecting the presence of a Trk fusion protein or an NTRK rearrangement in a non-neuroendocrine tumor sample according to the method of any one of Embodiments 44 to 45, and selecting the patient to receive the therapy if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC or the NTRK rearrangement is detected.

The foregoing disclosure of the exemplary embodiments is for purposes of illustration and description. it is not intended to be an exhaustive list of embodiments of the invention or to limit the subject disclosure to the precise forms disclosed. Many variations and modifications of the embodiments described herein will be apparent to one of ordinary skill in the art in light of the above disclosure.

Further, in describing representative embodiments disclosed herein, the specification may have presented the method and/or process of the present subject disclosure as a particular sequence of steps. However, to the extent that the method or process does not rely on the particular order of steps set forth herein, the method or process should not be limited to the particular sequence of steps described. As one of ordinary skill in the art would appreciate, other sequences of steps may be possible. Therefore, the particular order of the steps set forth in the specification should not be construed as limitations on the claims. In addition, the claims directed to the method and/or process of the present subject disclosure should not be limited to the performance of their steps in the order written unless explicitly stated or otherwise clear from the context, and one skilled in the art can readily appreciate that the sequences may be varied and still remain within the spirit and scope of the present subject disclosure..

VII. References

The following references are hereby incorporated by reference in their entirety:

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1. The method of detecting a fusion protein of TrkA, TrkB, or TrkC in a non-neuroendocrine tumor sample, the method comprising: affinity histochemically staining the sample with a biomarker-specific reagent that specifically binds to an amino acid sequence comprising residues 363-760 of SEQ ID NO: 1, an amino acid sequence comprising residues 646-838 of SEQ ID NO: 2, and an amino acid sequence comprising residues 718-839 of SEQ ID NO: 3; detecting a staining pattern in the sample; and scoring the sample as positive for a fusion protein involving TrkA, TrkB, or TrkC if the sample has a staining pattern in which greater than or equal to a threshold percentage of tumor cells stain above a threshold specific staining intensity.
 2. The method of claim 1, wherein the percentage of tumor cells staining above the threshold specific staining intensity is a percentage of tumor cells in the entire tumor area.
 3. The method of claim 1, wherein the threshold percentage of tumor cells is in the range of 50% to 75% and the threshold staining intensity is at least 1.5.
 4. The method of claim 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is 1.75.
 5. The method of claim 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is 1.75.
 6. The method of claim 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is 1.75.
 7. The method of claim 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is
 2. 8. The method of claim 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is
 2. 9. The method of claim 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is
 2. 10. The method of claim 3, wherein the threshold percentage of tumor cells is 50% and the threshold staining intensity is
 3. 11. The method of claim 3, wherein the threshold percentage of tumor cells is 60% and the threshold staining intensity is
 3. 12. The method of claim 3, wherein the threshold percentage of tumor cells is 75% and the threshold staining intensity is
 3. 13. The method of claim 2, wherein the sample has a membranous and/or cytoplasmic staining pattern.
 14. The method of claim 1, wherein the percentage of tumor cells staining above the threshold specific staining intensity is a percentage of tumor cells within a tumor cell area having a threshold level of contiguous tumor cells.
 15. The method of claim 14, wherein the threshold level of contiguous tumor cells is at least 20 contiguous cells, the threshold percentage of cells is in the range of 20% to 90%, and the threshold staining intensity is any specific staining above background.
 16. The method of claim 14, wherein the threshold level of contiguous tumor cells is at least 20 contiguous cells, the threshold percentage of cells is in the range of 20% to 90%, and the threshold staining intensity is 0.5.
 17. The method of claim 14, wherein the threshold level of contiguous tumor cells is at least 50 contiguous cells and the threshold percentage of cells is at least 80%, and the threshold staining intensity is any specific staining above background.
 18. The method of claim 14, wherein the threshold level of contiguous tumor cells is at least 50 contiguous cells and the threshold percentage of cells is at least 80%, and the threshold staining intensity is 0.5.
 19. The method of claim 14, wherein the sample has a nuclear staining pattern.
 20. The method of claim 1, wherein the biomarker-specific reagent is an antibody.
 21. The method of claim 20, wherein the affinity histochemically staining comprises: (a) subjecting the sample to a heat-induced epitope retrieval process; and (b) contacting the sample with the biomarker-specific reagent and a set of detection reagents to deposit a brightfield dye in proximity to any biomarker-specific reagent bound to the sample.
 22. The method of claim 21, wherein the set of detection reagents comprises a secondary antibody immunoreactive with the antibody, a tertiary antibody immunoreactive with the secondary antibody conjugated to an enzyme, and a set of reagents reactive with the enzyme to effect deposition of a brightfield dye on the sample.
 23. The method of claim 22, wherein the secondary antibody is haptenated and the tertiary antibody is an anti-hapten antibody.
 24. The method of claim 21, wherein the brightfield dye is 3,3′-diaminobenzidine (DAB).
 25. A method of selecting a patient to receive a Trk-directed therapy, comprising detecting the presence of a Trk fusion protein in a non-neuroendocrine tumor sample according to a method of claim 1, and selecting the patient to receive the therapy if the sample is scored as positive for a fusion protein involving TrkA, TrkB, or TrkC.
 26. A method of detecting an NTRK rearrangement in a non-neuroendocrine tumor sample, the method comprising: detecting the presence of a Trk fusion protein in the sample according to claim 1, scoring the sample as Trk Fusion Positive, Trk Fusion Equivocal, or Trk Fusion Negative, and screening for the NTRK rearrangement by sequencing, reverse transcriptase polymerase chain reaction, or in situ hybridization if the sample is scored as Trk Fusion Positive or Trk Fusion Equivocal samples.
 27. A method of selecting a patient to receive a Trk-directed therapy, comprising detecting the presence of a Trk fusion protein or an NTRK rearrangement in a non-neuroendocrine tumor sample according to the method of claim 26, and selecting the patient to receive the therapy if the NTRK rearrangement is detected. 